Northern Queensland Medicare Mental Health Phone Service Connection Form 
Forward completed referral via Medical Objects ID: MENTAL HEALTH NQLD REFERRALS,  MEDICARE  (TH4218000D3) or via email to: mmh-nqld@pccs.org.au  Phone: 1800 595 212

Servicing people in the Northern Queensland PHN area, Medicare Mental Health Phone Service provides a free, confidential referral service for anyone seeking help for their wellbeing or wanting support for a patient or someone they care about. 
Whether you know what service is required, or the person you are referring needs help to explore options, the Medicare Mental Health Phone Service team can help find services or supports to assist. 
If the person has acute mental health needs, please refer to MH Call on 1300 64 22 55.	

About the person you are referring 	
Full Name 	<<Patient Demographics:Full Name>>	
Preferred Name	<<Patient Demographics:Known As>>	
Date of Birth	<<Patient Demographics:DOB>>	
Address	<<Patient Demographics:Full Address>>	
Phone Number	<<Patient Demographics:Phone (Mobile)>>	
Email 	<<Patient Demographics:E-mail>>	
Preferred contact method (select all that apply)	Phone call 	
<<Preferred contact method: Phone call>>	

Text	
<<Preferred contact method: Text>>	

Email	
<<Preferred contact method: Email:>>	

Is the person comfortable with us contacting a family member, friend, or other support person if we are unable to reach them? 
If so, please complete the details. 	Yes	
<<Is the person comfortable with us contacting a supp>>	
No	
<<Is the person comfortable with us contacting a supp>>	

Name	
<<Support person name?>>	

Relationship	
<<Support person relationship?>>	

Phone number	
<<Support person phone number?>>	

Is an interpreter required? 	<<Is an interpreter required?>>	

<<If yes, please specify language: >>	

Is there anything else important to share about the person you are referring? E.g ethnic background, gender identity, preferred practitioner gender, etc	<<Anything else to share about person being referred?>>	

Referral notes	
What does the person want help with?	<<What does the person want help with?>>	
Do they know what type of service or support they want?	<<Do they know service or support they want? >>	
Based on your patient’s input, as the referring GP, do you have any recommendations about suitable services or supports?	<<Based on pt input, do you have recommendations?>>	
Are there any particular challenges or situations that will make it hard for the person to engage in a service or support? E.g. transport	<<Any challenges to make it harder? eg transport>>	

About the referring GP	
Date Referred by GP	<<Miscellaneous:Date>>	
Full Name	<<Doctor:Name>>	
Address	<<Doctor:Full Address>>	
Practice name	<<Practice/Location:Name>>	
Contact details	Phone 	
<<Doctor:Phone>>	

Email	
<<Doctor:E-mail>>	

About the care team – Who would the person you’re referring like to keep updated about their care journey?  	
Please provide Name, Role/Organisation and contact details	
<<Name of person to keep updated?>>	
<<Role/organisation to keep updated? >>	

	

If you have completed a Mental Health Treatment Plan (MHTP) or used the Initial Assessment and Referral Decision Support Tool (IAR-DST) please attach with the referral.	

Consent to share information 	
By consenting to this referral, the person is consenting to the sharing of their personal information. The information contained in the referral is used by the Medicare Mental Health Phone Service to: 
(1) deliver assessment and referral services, 
(2) for monitoring, aggregate reporting and evaluation purposes to improve quality and access to care. 
This information will be passed on to the recommended provider who will contact the person.	
Please indicate this form’s information has been discussed and provided to the patient. <<This forms info discussed/[provided to patient? >>
Patient or Parent/Guardian/Carer consents to referral? <Patient or Parent/Carer/Guardian consents to referral?> 
Referrer consents to the collection and storage of referrer details on internal database? <Referrer consents to the collection and storage of referrer details on internal database?>